Broxap Limited Vacancy Application Form. SECTION A This form should be completed in black ink or type DETAILS OF VACANCY PERSONAL DETAILS

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1 IMPORTANT INFORMATION FOR APPLICANTS Applicants should read the following notes carefully before beginning to complete this application form. Broxap Limited values diversity and is working towards creating a culture which seeks, respects, values and harnesses differences. In so doing, we are endeavouring to improve our understanding of the differing needs of women, people from minority ethnic groups, disabled people and other marginalised groups who use and provide our services. This application form has been designed to assist us to work towards this goal. It comprises fours parts, Sections A, B, C together with a Monitoring Form. Boxed sections can be completed by a click of the mouse. Section A contains general information relating to personal details and employment status Section B contains essential information to help determine whether candidates meet the skills required for the role Section C reference details and declaration. Monitoring Form It is therefore essential that this application form is fully completed as it will be used to determine whether you meet the skills requirements. If you have any special needs/requirements to enable you to complete this form, please contact us. A Curriculum Vitae (CV) may be submitted as part of your application. In these circumstances, please ensure that personal details and information relating to skills, abilities, knowledge and experience are included. If preferred, you may submit a CV in place of Section B, but please complete Sections A + C and forward this with your application. If you are successful in gaining employment with the Company, this form and the information it contains will form part of your personnel record. If you are unsuccessful, the information will be destroyed after a period not exceeding six months from the closing date. In all cases, the information will be held securely in accordance with the Data Protection Act. SECTION A This form should be completed in black ink or type DETAILS OF VACANCY Job Title: Department: PERSONAL DETAILS Surname/Family Name: Title: Mr/Mrs/Miss/Ms/Dr (please delete) Address: Postcode: Do you hold a valid driving licence Do you have any endorsements If YES, state endorsements and dates: FOR OFFICE USE ONLY Candidate Reference Number: Site: Closing Date: First Name (s): Telephone Number Home: Mobile Number: address:

2 ASYLUM AND IMMIGRATION To comply with Asylum and Immigration legislation you will be required, if appointed, to provide at least one document from the specified list which provides evidence of your entitlement to work in the UK. Please click at least one of the following original documents that you will be able to provide when requested. A passport or national identity card confirming that you are either a British Citizen or a European Economic Area national or which shows that you are otherwise entitled to live and work in the United Kingdom. A full UK birth certificate confirming birth in the United Kingdom or Republic of Ireland. A letter from the Home Office confirming that you are allowed to work. A residence permit, registration certificate or document certifying or indicating permanent residence issued by the Home Office, the Border and Immigration Agency or the UK Border Agency. A permanent residence card or document issued by the Home Office, the Border and Immigration Agency or the UK Border Agency. A passport or other travel document endorsed to show that the holder is exempt from immigration control, is allowed to stay indefinitely in the United Kingdom, has the right of abode in the United Kingdom, or has no time limit on their stay in the United Kingdom. An Immigration Status Document issued by the Home Office, the Border and Immigration Agency or the UK Border Agency to the holder with an endorsement indicating that the person named in it is allowed to stay indefinitely in the United Kingdom or has no time limit on their stay in the United Kingdom. A full adoption certificate issued in the United Kingdom which includes the name (s) of at least one of the holder s adoptive parents. DISCLOSURE The company welcomes applications from all candidates. Criminal records will be taken into account for recruitment purposes when the conviction is relevant. Unless the nature of the work demands it, you will not be asked to disclose convictions which are spent under the Rehabilitation of Offenders Act Having an unspent conviction will not necessarily bar you from employment. NB: A conviction is considered spent for sentences as detailed below: - Less than 6 months Spent after 7 years 6 months 2 ½ years Spent after 10 years 2 ½ years or more Always unspent Having you any previous convictions? If YES, please give details of the offence (s), including the date and sentence: The Rehabilitation of Offenders Act 1974 requires applicants to give details of any convictions which are not spent. Failure to disclose such convictions could result in disciplinary action or dismissal.

3 SECTION B DETAILS OF POST APPLIED FOR Job Title: FOR OFFICE USE ONLY Candidate Number: Department: EDUCATION Secondary, Further and Higher (a) SECONDARY subjects specify GCSE, CSE, O, A levels, etc School/College From To Subject and Level Grade (b) FURTHER AND HIGHER College/University From To Subject and Level Grade/Class (c) PROFESSIONAL QUALIFICATIONS/MEMBERSHIP OF PROFESSIONAL BODIES Professional Body/Association Current Level of Membership Method of achievement, e.g. application, examination, invitation Membership Number NB Qualifications will be checked and verified from time to time

4 TRAINING/DEVELOPMENT/LEARNING (Please list relevant training undertaken) PRESENT/LAST EMPLOYER (Please delete as appropriate) Job title: Date appointed: Current Salary: Name and address of Employer: Other Benefits: tice Period Postcode: Telephone Number: Brief description of duties and responsibilities, skills and qualifications required to undertake the role: Dates when NOT available for interview: (NB Every effort will be made to avoid these dates but this may not always be possible Reason for leaving/wanting to leave:

5 PREVIOUS EMPLOYMENT In date order, starting with the most recent. Continue on a separate sheet of paper if necessary. Previous employers may be contacted to validate information provided. Name and Address of Employer From Month & Year To Month & Year Position Held and Brief outline of the role Reason for leaving SUPPORT INFORMATION Please describe how your skills, abilities, knowledge and experience is relevant to this role. You may include any unpaid work or other outside interests if appropriate. (Continue on a separate sheet if necessary).

6 SECTION C REFERENCES Please give the name and address of two people, one of whom must be your present employer (or if unemployed, your last employer) to whom references can be made. If this is your first employment, please use your school/college. Appointments will be made subject to satisfactory references. Present/Last Employer Name: Name: Title/Position: Title/Position: Address: Address: Postcode: Telephone Number: address: Postcode: Telephone Number: address: NB: References will be sought if you are short-listed for interview. If at this stage you do not want your current employer contacted, please click the box. References for successful candidates will be followed up and verified. DECLARATION I declare that all the information I have provided is true. I understand that if any information disclosed is found to be false following appointment, I may be liable to dismissal without notice. I also declare that there is no reason why I should be considered unsuitable to work with children/vulnerable adults and I confirm that I have not been barred from carrying out regulated activity. Signature: Date: To your knowledge, are you related to or do you know any individual(s) currently employed by the Company? If yes, whom? Please return your completed application form to: HR Department Broxap Limited Rowhurst Industrial Estate Chesterton Newcastle Under Lyme Staffs ST5 6BD or recruitment@broxap.com Thank you for taking the time to complete this application. Please remember to include the Job Title when you complete the form.

7 Monitoring Form Monitoring Form The information provided on this form is to ensure that Broxap complies with achieving Equality and Diversity in the workplace. To enable us to do this, we would be grateful if you could provide us with information about yourself as follows: Gender Are You: Female Male Other description Question declined Ethnicity Are You: White British White & Black Caribbean White Irish White & Asian Mixed Other Asian/Asian British: Indian Asian/Asian British: Bangladeshi Black/Black British: Caribbean Black/Black British: Other Chinese t Known White & Black African White Other Asian/Asian British: Pakistani Asian/Asian British: Other Black/Black British: African Other Ethnic Group t Disclosed Name: Date of Birth: Disability - Do you consider yourself to have a disability? Question declined If YES, please give brief details of your disability to assist us in our in our endeavours to monitor equal opportunities Please identify any special requirements or reasonable adjustments which would assist you: a) In the recruitment process: b) To enable you to carry out the job: Sexual Orientation - How would you describe your sexual orientation? Heterosexual Homosexual Bisexual Trans Question declined Religious Belief - What is your religious belief? Buddhist Muslim Christian Religion Sikh Hindu Jewish Question declined Other religious beliefs (specify) Marital Status - How would you describe your status? Single Married/Civil Partnership Widowed Divorced Asylum & Immigration Act In order to comply with the Immigration, Asylum and Nationality Act 2006 the successful candidate will be asked to provide evidence of his/her ability to work in the UK before commencing employment. Do you have the right to work in the UK? Data Protection This form will be detached and will not be seen by the selection panel. Information in this application will be kept confidentially by the Company and used for the exclusive purposes of recruitment and employment. Once the recruitment and selection process is complete, the data will be stored and used for your personnel records should you be the successful applicant. Please indicate your consent for your information to be used for this purpose.

8 Please return your completed form to: HR Department, Broxap Ltd, Rowhurst Industrial Estate, Chesterton, Newcastle under Lyme, Staffordshire, ST5 6BD